Sage Journals: Discover world-class research

Abstract

Introduction

Effectiveness of Patient Education Materials (PEMs) on NSAIDs is subjected to whether the patient is able to read and comprehend the information provided. This study assessed the readability, understandability and actionability of English-language NSAID-related PEMs targeted at patients or caregivers in Singapore.

Methods

PEMs obtained from healthcare institutions in Singapore and from two frequently used internet search engines using search terms “NSAID” or “non-steroidal anti-inflammatory drug” were analysed by two reviewers using Flesch-Kincaid Grade Level (FKGL) and Simple Measure of Gobbledygook (SMOG) to assess the readability of the PEMs. Patient Education Materials Assessment Tool for printable materials (PEMAT-P) and United Kingdom Association for Accessible Formats (UKAAF) was used to assess the PEMs’ understandability, actionability and physical properties.

Results

All 74 PEMs that were reviewed, except one, were assessed to be beyond readability of the general population which was defined as grade 6 and below. Their mean FKGL and SMOG scores were 13.3 ± 2.8 and 14.4 ± 2.1 respectively. There were no significant differences in the FKGL (p = .20) and SMOG scores (p = .52) between local and non-local PEMs. The PEMs satisfied majority of UKAAF’s requirements. The PEMs’ understandability and actionability scores were 80.5 ± 8.0% and 52.5 ± 19.0% respectively.

Conclusions

Current NSAIDs-related PEMs are pegged too high at a level for a significant portion of population in Singapore to read and comprehend the information for them to take appropriate actions to ensure safe use of NSAIDs to manage their medical conditions. However, they are generally well-designed to facilitate reading of the materials.

Keywords

Comprehend cyclooxygenase-II inhibitors drug information non-steroidal anti-inflammatory drug readability

Introduction

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used worldwide for their analgesic, anti-inflammatory and antipyretic effects.¹ However, NSAIDs may also be associated with deleterious side effects such as gastrointestinal ulcers and haemorrhage, cardiovascular disease and acute kidney injury.^2,3 Despite prescribing guidelines from internationally renowned societies and dispensing interventions,^2,4 NSAID use remains prevalent among susceptible individuals such as older adults and those with cardiovascular, kidney and gastrointestinal risks.^2,5,6 In particular, over-the-counter (OTC) purchases constituted 78% of NSAID use among older adults in Sweden.⁷ OTC NSAIDs may contribute to the potentially inappropriate use of NSAID in at-risk individuals, since studies have identified gaps in patients’ knowledge regarding excessive dosing and concurrent exposure to other medications that may potentiate the risk of NSAID-associated adverse events.^8,9

Hence, there is growing recognition that there is a need to improve the self-care knowledge and health literacy of at-risk individuals,⁸ so that they can understand, evaluate and apply NSAID-related information to make informed health decisions regarding their use.^10,11 Patient Education Materials (PEMs) in written and electronic forms are favoured since they are easily reproducible and can be dispensed by healthcare professionals to educate patients on the correct and appropriate use of NSAID. Yet, their effectiveness to improve patients’ health literacy may be compromised if the target users are unable to understand the PEMs. Data on the quality of NSAID-related PEMs that patients may encounter is scanty despite NSAIDs being one of the most used analgesics. Though Singapore currently has one of the best education system globally, about a quarter of its residential population aged 25 years and above in 2019 had only completed primary school education.¹² Older residents (42.1% of those aged 55 years and above)¹² made up a significant proportion of this group. There is thus concern whether current NSAID-related PEMs are written to match the literacy and reading capability of the general population. We conducted this study to assess the readability, understandability and actionability of NSAID-related PEMs available to the local population.

Methods

Data collection

English is the official national language and the latest census in 2020 reported that English was the language most frequently spoken at home in the resident population (48.3%).¹³ Hence English-language NSAID-related PEMs targeted at patients or caregivers were included for this study.

All public and private hospitals, public primary care polyclinics, and a random selection of 50 private general practice clinics in Singapore were invited by phone call and mail to share their printed NSAID-related PEMs. A return mail was attached to each invitation to facilitate their sharing. NSAID-related PEMs were also obtained from the websites of these healthcare institutions using the search terms “NSAID” or “non-steroidal anti-inflammatory drug”. The internet may also be a source of medicines information as 98% of households have Internet access and 89% of residential population were Internet users in 2019.¹⁴ Hence two frequently used internet search engines, Google and Yahoo, were used to identify NSAID-related PEMs that patients and caregivers may encounter. The following search terms were used: ‘NSAID information’, ‘nonsteroidal anti-inflammatory drug information’, NSAID patient education material’ and ‘nonsteroidal anti-inflammatory drug patient education material’ for an online search between Jan and July 2020. NSAID-related PEMs were downloaded or copied from the websites hosted by private and national corporations with materials approved by their expert panels, health education units of medical schools, centres or healthcare institutions, health information providers and not-for-profit organizations as directed by weblinks that showed one or more of the above search terms.

Readability

Readability is an objective measure of how well an individual understands the text that he/she reads and it is measured in terms of level of education.¹⁵ PEMs with readability beyond grade 6 (equivalent to completing primary school in the local context) was defined as difficult according to recommendations from the American Medical Association and the National Institute of Health.

The Flesch-Kincaid Grade Level (FKGL) and Simple Measure of Gobbledygook (SMOG) were used to assess the readability of the PEMs for this study. Although several validated readability assessment tools such as Flesch Reading Ease score, Gunning Fog Index and Fry Readability Graph are available, the FKGL is an extensively validated tool that is highly correlated with the readers’ education level and with other readability formulas and is easy to administer.¹⁵ The FKGL score is generated using the formula: 0.39 (words/sentences) + 11.8 (syllables/words) −15.59.¹⁶ The higher the FKGL score, the greater the difficulty in comprehending the text. FKGL for this study was calculated using the readability statistic in Microsoft Word. A FKGL of 5^th grade with Flesch Kincaid Reading Age (FKRA) of 5.9 and below is defined as very easy to read while a 6^th grade (FKRA: 6.0-6.9) is defined as easy to read.¹⁷ A 7^th grade (FKRA: 7.0-7.9) defined as fairly easy to read, 8^th and 9^th grade (FKRA: 8.0-9.9) as conversational English, 10^th, 11^th and 12^th (FKRA: 10.0-12.9) grades as fairly difficult to read.¹⁷ A FKRA of 13.0-15.9, 16.0-17.9, and 18.0 and above are defined as difficult to read, very difficult to read and extremely difficult to read.¹⁷

The SMOG, calculated via the formula: 3.1291 + 1.0430√number of polysyllabic words in samples of 30 sentences,¹⁸ was also used to assess the readers’ readability because of its stricter assessment criterion which requires any reading material of a certain SMOG readability grade to be comprehensible by all individuals with that reading grade skills. This 100% comprehension ability criterion is not a requirement of other readability assessment tests mentioned earlier.¹⁸ The higher the SMOG index, the greater the difficulty in comprehending the text.¹⁵ A SMOG index of 4-5 which corresponds directly to school grade of 4-5 respectively is defined as very easy to read, while a SMOG index of 6, 7 and 8-9 are defined as easy to read, fairly easy to read and conversational English respectively.¹⁹ A SMOG index of 10-12, 13-16 and 17 are defined as fairly difficult to read, difficult to read and very difficult to read respectively.¹⁹ A SMOG index of 18 and above is defined as extremely difficult to read.¹⁹

The SMOG scores were calculated using an online calculator accessed at https://www.textcompare.org/readability/smog-index.¹⁹ As the validated SMOG assessment tool only counts text up to a maximum of 30 sentences,¹⁸ 10 consecutive sentences at the beginning, middle and end of the text were selected from texts were longer than 30 sentences.¹⁸

The PEMs were prepared for computerised readability assessment via the following steps:

• Text were copied directly or manually transcribed from the softcopy and hardcopy printed material into a Microsoft Word file.¹⁹

• Titles, subtitles, headings, captions and visual aids were omitted as only complete sentences with running text which end with a full stop, exclamation or question mark will be involved in the count.¹⁹

• Colons and semicolons within a sentence were removed.¹⁹

• Decimal point of number were removed.¹⁹

• Text such as copyright notice, disclaimers and author names that were not related to patient education were omitted.¹⁹

• Abbreviations were spelled out.

• Numbers and symbols were spelled out.¹⁸

• For bullet points which could be considered as a sentence were formatted as complete sentence while those which could not be considered as a sentence, a preamble was added in front of each bullet point to form a complete sentence.¹⁸

Format quality

The physical properties of the PEMs, such as the layout and design can affect the readability and comprehension of the reader.^20,21 Alterations in typography of the reading materials may affect the reading rate, reading accuracy and comprehension.²² The United Kingdom Association for Accessible Formats (UKAAF) stipulated 10 criteria for producing clear and large print for documents to the reading materials to most people, including those with low vision.²³

Understandability and actionability

Understandability of a PEM is related to whether the patient is able to process and explain key messages from the PEM, while actionability of the PEM is related to whether patients can identify what they can do based on the information presented.²² The Patient Education Materials Assessment Tool for printable materials (PEMAT-P), the first validated scale to measure the understandability and actionability of PEM,³⁴ was chosen for its strong internal consistency, reliability, and evidence of construct validity.²⁴ The PEMAT-P consists of a 19-item understandability scale and a 7-item actionability scale.²⁵ Each item in the PEMAT-P has the response options of “Agree” and “Disagree”. Some items have additional response option of “NA” where applicable. A score of “1” was awarded for each “Agree” response while “0” was awarded for each “Disagree” response.²⁵ Each PEM was assessed independently by two authors (with initials BG and ST). The PEMAT-P understandability and actionability scores were calculated by dividing the total points scored by the PEMs by the total possible points and expressed as percentages. The higher the score, the more understandable or actionable the material.

Statistical analysis

All analyses were performed using Microsoft Excel and IBM SPSS Statistics 27 (IBM Corp., Armonk, New York). Categorical variables were presented as proportions and compared using Pearson chi-square test or Fisher’s test as appropriate. Continuous variables were summarised as means with standard deviations and compared using the Mann Whitney U test. All tests were two-tailed and statistical significance was defined as p < .05.

Results

This study identified 74 PEMs: 7 local PEMs were obtained from the online websites of local healthcare institutions (6 from public hospitals, one from public primary care institution and none from private general practice clinics) and 67 non-local PEMs were obtained from websites hosted by institutions outside of the country. NSAID PEMs (physical and online) from the local private hospitals and general practice clinics were not available.

Table 1 showed the aspects of NSAID-related information classified into 12 categories for (1) all PEMs, (2) local PEMs and (3) non-local PEMs. A mean of 6.4 ± 1.7 categories was included in the PEMs. The number of categories of drug information included in the local PEMs was not significantly different compared to the non-local PEMs (7.6 ± 2.2 vs 6.3 ± 1.6 respectively, p = .17). The most frequently mentioned content were examples, indications, precautions or contraindications and common side effects of NSAIDs. Information on administration, storage and action to be taken in event of a missed dose were more frequently found in local PEMs.

Table 1.

Content covered by non-steroidal anti-inflammatory drug (NSAID)- related patient education material (PEM).

	All PEM, N = 74		Local PEM, N = 7		Non-local PEM, N = 67		P-value^a
	Number	Percentage	Number	Percentage	Number	Percentage	P-value^a
Examples of NSAIDs	74	100	7	100	67	100	0.65
Indications	73	98.6	7	100	66	98.5	0.85
Precautions/Contraindication	71	95.9	7	100	64	95.5	0.88
Common side effects	67	90.5	7	100	60	89.6	0.57
Mechanism of action	43	58.1	2	28.6	41	61.2	0.08
Administration	41	55.4	7	100	34	50.7	0.03
Drug interactions	40	54.1	2	28.6	38	56.7	0.13
Pregnancy/Breastfeeding	34	45.9	3	42.9	31	46.3	0.76
Onset of action	9	12.2	1	14.3	8	11.9	0.96
Storage	8	10.8	5	71.4	3	4.5	<0.001
Dosage forms	8	10.8	1	14.3	7	10.4	0.95
What to do if a dose is missed	6	8.1	4	57.1	2	3.0	<0.001

^aPearson chi-square test or Fisher’s exact test was used to compare between local and non-local PEM as appropriate.

Readability

Table 2 shows that the FKGL and SMOG scores of the NSAID-related PEMs were generally high, such that most of the PEMs would be considered difficult for the general population. There were no significant differences in the FKGL (p = .20) and SMOG scores (p = .52) between local and non-local PEMs. None of the local PEMs assessed by either FKGL or SMOG met the recommended readability level of grade 6 and below (the equivalent of primary school education),¹⁸ while only one non-local PEM did. Supplemental Table S1 showed that most of the PEMs were assessed to be fairly to extremely difficult to read when assessed by both readability assessment tools.

Table 2.

Readability, understandability and actionability of NSAID-related patient education materials.

	Flesch-kincaid grade level		SMOG index		PEMAT-P understandability			PEMAT-P actionability
	Mean±SD	Min-Max	Mean±SD	Min-Max	Score, %	Lowest score, %	Highest score, %	Score, %	Lowest score, %	Highest score, %
All PEMs	13.3 ± 2.8	6.0-18.5	14.4 ± 2.1	9.3-19.1	80.5 ± 8.0	46.2	100.0	52.5 ± 19.0	0.0	83.3
Local PEMs	12.6 ± 0.7	11.9-13.7	14.3 ± 0.6	13.2-14.9	90.2 ± 7.5	81.8	100.0	62.9 ± 7.6	60.0	80.0
Non-local PEMs	13.3 ± 2.9	6.0-18.5	14.4 ± 2.2	9.3-19.1	79.5 ± 7.4	46.2	91.7	51.4 ± 19.5	0	83.3

PEMs, patient education materials; NSAID, non-steroidal anti-inflammatory drug; SMOG, simple measure of gobbledygook; PEMAT-P, patient education materials assessment tool for printable materials; min, minimum; max, maximum; SD, standard deviation.

Format quality

The PEMs satisfied the majority of the UKAAF requirements (Supplemental Table S2). However, only half of the PEMs had font size of 12 or larger. The other format quality issues identified were use of large blocks of capital letters and narrow line spacing between the sentences, which made reading difficult.

Actionability and understandability

Table 2 shows the understandability and actionability of NSAID-related PEMs assessed according to PEMAT-P. The understandability scores were generally higher than the actionability scores. The local PEMs had significantly higher understandability scores than the non-local PEMs (90.2 ± 7.5 vs 79.5 ± 7.4 respectively, p = .006) and tended to have higher actionability scores (62.9 ± 7.6 vs 51.4 ± 19.5, respectively, p = .08).

Discussion

This study identified 74 NSAID-related onli PEMs, including 7 from websites hosted by local healthcare institutions. Only one met the recommended readability level of grade 6 and below (the equivalent of primary school education) as recommended by the American Medical Association and the National Institute of Health.²⁶ Notably, the older individuals who may be most at-risk for NSAID-related adverse events formed almost half of those with lower formal education, possibly due to limited educational opportunities during early nation-building. An Economic Co-operation and Development (OECD) report in 2016 noted that fewer than a third of Singapore adults were able to read dense or lengthy text which requires a reader to identify, evaluate and infer information.²⁷ While the NSAID-related PEMs evaluated in this study covered many categories of drug information, this supposedly useful information may not be properly understood by patients or their caregivers. Similarly, prior studies on written and online PEMs for diabetes, ophthalmology and peripheral neuropathy in other countries were found to be above the reading capability and comprehension level of the average patient.^28–31 Such mismatches may result in imperative information being misunderstood or missed by the patients which in turn may lead to inappropriate or even erroneous NSAID use, thus posing a medication safety concern when PEMs are used to supplement medication counselling. However, as the literacy rate increases in subsequent years, future research will be required to re-evaluate the findings to determine the appropriate target education level for NSAID-related PEMs.

Interestingly, the local PEMs scored better in understandability and actionability than non-local PEMs. The PEMAT-P tool facilitates comparisons between different PEMs,²² but does not recommend a cutoff score to define the optimum understandability or actionability of PEMs.²⁵ While the PEMAT-P tool is designed to be completed by healthcare professional who aim to select the most suitable PEM for patient care, the understandability and actionability of PEMs may also be assessed by a large and varied pool of patients who are the target users of the NSAID-related PEMs to obtain a more representative perspective that can be taken into consideration when developing or improving NSAID-related PEMs.³²

There are limitations in this study. Singapore is a multi-language society with diverse demographic, including seniors with low education levels and may primarily converse and/or literate in languages other than English. The retrieval of only English-language written PEMs using our pre-defined search terms may have restricted the PEMs included in the study, while patients may potentially search for PEMs in other languages. This study did not include video or audio PEMs. The PEMAT-P understandability and actionability was assessed by trained pharmacists as recommended by the PEMAT user guide, but may not be generalised to the general population with a different socioeconomic and education profile. Although almost half of the PEMs that were analyzed in this study had small font size, this may be less of a concern for online PEMs since the font size can be enlarged by the text adjustment function in electronic devices. Since the written form is among the most effective methods to disseminate medication-related information and improve patients’ medication knowledge and adherence,^33,34 the findings from this study can help identify aspects where the NSAID-related PEMs should be improved so that patients and caregivers can derive the intended benefits. Future studies could look into the readability, understandability and/or actionability of NSAID-related PEMs written in other languages to ensure that they are written at a level that patients can read and comprehend.

Conclusion

Supplemental Material

Supplemental Material - Patient educational materials on non-steroidal anti-inflammatory drugs

Supplemental Material for Patient educational materials on non-steroidal anti-inflammatory drugs by Bandy Qiuling Goh, Cynthia Lim Ciwei, Sheila Toh Kai Xuan, Puay Hoon Lee and Ngiap Chuan Tan in Proceedings of Singapore Healthcare

Footnotes

Author contributions

All authors have contributed significantly and agree with the content of this review article.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Bandy Qiuling Goh

Ngiap Chuan Tan

Supplemental Material

Supplemental material for this article is available online.

References

Day

Graham

. Non-steroidal anti-inflammatory drugs (NSAIDs). BMJ Br Med J (Clin Res Ed) 2013; 346: f3195.

Szeto

C-C

Sugano

Wang

J-G

, et al. Non-steroidal anti-inflammatory drug (NSAID) therapy in patients with hypertension, cardiovascular, renal or gastrointestinal comorbidities: joint APAGE/APLAR/APSDE/APSH/APSN/PoA recommendations. Gut 2020; 69(4): 617–629.

Lim

Ang

ATW

Kadir

HBA

, et al. Short-course systemic and topical non-steroidal anti-inflammatory drugs: impact on adverse renal events in older adults with Co-morbid disease. Drugs Aging 2020; 38(2): 147–156.

Panel

AGSBCUE

Fick

Semla

. American Geriatrics Society 2019 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2019; 67: 674–964.

Zeng

Zhang

Doherty

, et al. Initial analgesic prescriptions for osteoarthritis in the United Kingdom, 2000–2016. Rheumatology 2021; 60: 147–159.

Lim

Choo

Kwek

, et al. Non-steroidal anti-inflammatory drug prescription in the young-old and very-old: type, route and burden of cardiovascular risk factors. Nephrol Dial Transplant 2021; 36, gfab092.–

Modig

Elmståhl

. Kidney function and use of nonsteroidal anti-inflammatory drugs among elderly people: a cross-sectional study on potential hazards for an at risk population. Int J Clin Pharm 2018; 40: 870–877.

Mullan

Weston

Bonney

, et al. Consumer knowledge about over‐the‐counter NSAIDs: they don't know what they don't know. Aust N Z J Publ Health 2017; 41: 210–214.

Kaufman

Kelly

Battista

, et al. Exceeding the daily dosing limit of nonsteroidal anti‐inflammatory drugs among ibuprofen users. Pharmacoepidemiol Drug Saf 2018; 27: 322–331.

10.

Sorensen

Van den Broucke

Fullam

et al. HLS-EU Consortium Health Literacy Project European, et al. Health literacy and public health: a systematic review and integration of definitions and models. BMC Publ Health 2012; 12: 80.

11.

Pai

Vassalotti

Fox

, et al. Association between NSAID exposure and kidney function decline in primary care patients. Kidney 2020; 1: 521–523. DOI: 10.34067/KID.0001102019.

12.

Ministry of Statistcis S . Highest qualification attained of resident population aged. Singapore: Government of Singapore, 2024.

13.

Singapore DoS . Census of population 2020- literacy & home language. Singapore: Government of Singapore, 2021.

14.

Authority IMD . Infocomm usage-households and individuals. Singapore: Infocomm Media Development Authority, 2020.

15.

Wang

L-W

Miller

Schmitt

, et al. Assessing readability formula differences with written health information materials: application, results, and recommendations. Res Soc Adm Pharm 2013; 9: 503–516.

16.

Kincaid

JPFRJ

Rogers

Chissom

. Derivation of new readability formulas (automated readability index, Fog count and Flesch reading Ease formula) for navy enlisted personnel. Memphis, TN: Naval Air Station 1975.

17.

Flesch

Textcompare.org.

Kincaid grade level readability. Readabilit.

18.

McLaughlin

. SMOG grading—a new readability formula. J Read 1969; 12: 639–646.

19.

Textcompare.org . SMOG index readability test’ Textcompare.org. Readabilit, 2021.

20.

Ivnik

Jett

. Creating written patient education materials. CHEST Journal 2008; 133: 1038–1040.

21.

Katzir

Hershko

Halamish

The effect of font size on reading comprehension on second and fifth grade children: bigger is not always better. PLoS One 2013; 8: 1–8.

22.

Shoemaker

Wolf

Brach

. Development of the Patient Education Materials Assessment Tool (PEMAT): a new measure of understandability and actionability for print and audiovisual patient information. Patient Educ Counsel 2014; 96: 395–403.

23.

Formats UAfA . UKAAF minimum standards: clear and large print. UK Association for Accessible Formats, 2012.

24.

Quality. AfHRa.

The patient education materials assessment tool (PEMAT) and user’s guide. Agency for Healthcare Research and Quality.

25.

Health NIo . Chronic pain: in depth. Office of Disease Prevention and Health Promotion, 2018.

26.

Abu-Heija

Shatta

Ajam

, et al. Quantitative readability assessment of the internal medicine online patient information on Annals.org. Cureus 2019; 11: e4184.

27.

OECD . Skills matter. Paris: OECD, 2016.

28.

Hansberry

Agarwal

Baker

. Health literacy and online educational resources: an opportunity to educate patients. AJR Am J Roentgenol 2015; 204: 111–116.

29.

Williams

Muir

Rosdahl

. Readability of patient education materials in ophthalmology: a single-institution study and systematic review. BMC Ophthalmol 2016; 16: 133.

30.

Roberts

Zhang

Dyer

GSM

. The readability of AAOS patient education materials: evaluating the progress since 2008. J Bone Joint Surg Am 2016; 98: e70.

31.

Bernard

Cooke

Cole

, et al. Quality and readability of online information about type 2 diabetes and nutrition. Journal of the American Academy of PAs 2018; 31: 41–44.

32.

Armstrong

Harries

. Patient information that promotes healt literacy. Nurs Times 2013; 109: 23–25.

33.

van Beusekom

Grootens-Wiegers

Bos

MJW

, et al. Low literacy and written drug information: information-seeking, leaflet evaluation and preferences, and roles for images. Int J Clin Pharm 2016; 38: 1372–1379.

34.

Wali

Hudani

Wali

, et al. A systematic review of interventions to improve medication information for low health literate populations. Res Soc Adm Pharm 2016; 12: 830–864.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.40 MB

Patient educational materials on non-steroidal anti-inflammatory drugs

Abstract

Introduction

Methods

Results

Conclusions

Keywords

Introduction

Methods

Data collection

Readability

Format quality

Understandability and actionability

Statistical analysis

Results

Contents

Readability

Format quality

Actionability and understandability

Discussion

Conclusion

Supplemental Material

Supplemental Material - Patient educational materials on non-steroidal anti-inflammatory drugs

Footnotes

Author contributions

Declaration of conflicting interests

Funding

ORCID iDs

Supplemental Material

References

Supplementary Material